complaint·October 25, 2023

reviewed the Trust Account/P & I Ledgers (March 2023 & October 2023), Incident Reports (02/21/23 – 03/01/23), Staff In-service Training Records, Monthly Menu (October 2023), Facility Staff (S1-S5) and Residents (R9-R12) files, Facility Staff and Residents' rosters (dated 02/23/22 & 10/06/23). LPA/RA toured the facility's physical plant: memory care unit, medication room, and commercial-size kitchen. LPA/RA observed the security monitors and camera system and delayed egress doors. Regarding Allegation #1 : this investigation revealed that the facility is a vendor of the Harbor Regional Center (HRC) and participant of the Assisted-Living Waiver program. Residents who require 24/7 level of care reside in the facility’s secured unit on the 2 nd floor that requires a key-card system. Interviews conducted of seven (7) staff corroborated that the facility does not have residents with a prohibited health condition. Executive Director stated that whenever a resident requires a higher level of care, facility staff will call 9-1-1 or non-emergency ambulance. If the facility receives a call regarding accepting/returning a resident with a prohibited health condition, they are advised that the facility is not a medical facility. Interviews conducted of eight (8) residents, corroborated that they did not have a prohibited health condition nor had they known of residents living in the facility with a prohibited health condition. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of LEVEL OF CARE: Staff are allowing residents with prohibited health conditions to reside in the facility is found to be UNSUBSTANTIATED. Regarding Allegation #2 : this investigation revealed based on interviews conducted of seven (7) facility staff who corroborated that whenever a resident has sustained a skin tear, the med techs will provide first-aid. Interviews conducted of eight (8) residents corroborated that they are provided with first aid by the med techs whenever they have sustained a skin tear. LPA/RA reviewed facility staff in-service training record on the topic of How to Manage Elderly Skin, Skin Integrity, and First Aid. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff are not preventing residents from sustaining skin tears while in care is found to be UNSUBSTANTIATED. Regarding Allegation #3 : this investigation revealed based on interviews conducted of seven (7) facility staff members corroborated that often a resident cannot hear so facility staff often has to raise their voice in an effort to communicate to the resident(s). There has been no complaints made to facility staff from residents regarding facility staff yelling at them. Interviews conducted of eight (8) of the residents corroborated that they have not been yelled at by a facility staff member nor observed other residents in care being yelled at by facility staff. LPA/RA reviewed the facility staff rosters (dated 02/23/22 & 10/06/23) that did not document a staff member by the first name of “Brenda” or “Marina” or “April”. LPA/RA reviewed facility staff in-service training records on the topic of Mandated Reporting. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff are yelling at the residents is found to be UNSUBSTANTIATED. Regarding Allegation #4 : this investigation revealed a tour of the facility’s physical plant was conducted upon arrival to ensure the health and safety of residents in care. Interviews conducted of seven (7) facility staff members corroborated that there has not been reports of abuse from residents or their representatives (ALW, PACE, HRC) or responsible person(s). Interviews conducted of eight (8) residents corroborated that they have not been abused by facility staff nor have they observed a resident in care being abused by a facility staff member. LPA/RA reviewed the facility staff rosters (dated 02/23/22 & 10/06/23) that did not document a staff member by the first name of “Brenda” or “Marina” or "April". LPA/RA reviewed facility staff in-service training records on the topics of Non-violent Crisis Intervention and Mandated Reporting. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff are abusing the residents while in care is found to be UNSUBSTANTIATED. Regarding Allegation #5 : this investigation revealed based on interviews conducted of seven (7) facility staff that 95 of the 97 residents in care have received both of their COVID-19 vaccines. Interviews conducted of eight (8) residents corroborated that they were not denied and have received both of their COVID-19 vaccinations. Administrator stated that residents from the PACE program received their vaccines through PACE and all other residents in care either received their vaccinations from the facility’s in-house doctor or CVS. LPA/RA observed facility’s Incident Reports to CCLD regarding COVID-19, staff in-service training record on the topic of Reducing Risk Keeping Safe & Preventing Spread, and (R9-R12) COVID-19 vaccination cards. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff denied residents the right to get a Covid-19 Vaccine is found to be UNSUBSTANTIATED. Regarding Allegation #6 : this investigation revealed based on interviews conducted of seven (7) staff members that there has not been complaints from residents in care that staff stole their money or personal belongings. Interviews conducted of eight (8) residents in care corroborated that they have not had money or personal belongings stolen by facility staff. Administrator stated that the facility maintains a trust account for every resident in care. LPA/RA reviewed facility’s Trust Account Ledgers (March 2023 and October 2023) for 45 residents. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS Staff are stealing money and personal belongings from residents is found to be UNSUBSTANTIATED. Regarding Allegation #7 : this investigation revealed based on interviews conducted of A1, A2, S1, and S2 that once the med techs administer residents’ medication(s), the med tech will initial the MAR. Interviews conducted of eight (8) residents corroborated that the med techs do administer their medications and have not been known to have missed medication(s). LPA/RA toured the medication room for observation of the medications and review of the medication administration records for R9-R12 that had been administered during the month of October 2023. LPA/RA reviewed facility staff in-service training on the topic of medication administration for Staff #2. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of MEDICATIONS: Staff are stealing residents’ medications is found to be UNSUBSTANTIATED. Regarding Allegation #8 : this investigation revealed based on interviews conducted of seven (7) staff members corroborated that they have not received complaints from residents that they were denied food. Staff #4 (Kitchen Aide/Server) indicated that if a resident should miss their mealtime (breakfast, lunch and/or dinner) there is always optional meals to select. Interviews conducted of eight (8) residents corroborated that they have not been denied a meal nor have they heard of a resident denied a meal. LPA/RA toured the commercial-size kitchen and observed a sufficient food supply of perishables and non-perishables including the posted monthly menu. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of FOOD SERVICE: Staff are denying residents food is found to be UNSUBSTANTIATED. Regarding Allegation #9 : this investigation revealed based on interviews conducted of seven (7) staff members corroborated that they have not received a complaint from residents in care that facility staff are not treating them with respect. Interviews conducted of eight (8) residents corroborated that facility staff are compliant and compassionate to their needs and have not been intimidated or bullied or threatened by a facility staff member. LPA/RA reviewed the facility staff rosters (dated 02/23/22 & 10/06/23) that did not document a staff member by the first name of “Brenda” or “Marina” or "April". LPA/RA reviewed facility staff in-service training record on the topics of Non-violent Crisis Intervention, Personal Rights, and Mandated Reporting. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff are not treating residents with dignity is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report provided to Staff #1 (Tyshima Bonner, Office Manager).